For some lucky bariatric patients, their journey will end after their target weight is reached. For others, however, a new journey will begin. Patients in the latter group are generally happy with their weight loss but discouraged because of the residual excess skin, fat, and sagging tissue.
Many patients present to the plastic surgeon’s office feeling like a failure despite massive weight loss (greater than 50 pounds), and state that they still feel “fat”.
This is a tragic disconnect that, sadly, I see in my office too frequently. Additional weight loss and physical training cannot correct these deformities – cosmetic rehabilitation can only be achieved by body contouring surgery.
The most common body contouring procedures include:
- Brachioplasty (upper arm contouring)
- Breast lift/reduction/augmentation
- Tummy tuck
- Body lift
- Thigh lift
It is important to understand that the anatomy in weight loss patients overall is the same as in non-weight loss patients, and the contouring procedures performed are similar to those performed in non-weight loss patients, but with some very significant differences.
One thing to always keep in mind is that after bariatric surgery, patients are not normal physiologically. Looks may be deceiving. Even full figured post-bariatric patients may be malnourished, and dehydrated. Healing from body contouring procedures burns tremendous amounts of calories and nutrients that need to be replenished.
Frequently the post-bariatric patient starts behind the nutrition eight ball, and after surgery is not able to eat enough to maintain, let alone heal. Metabolic disturbances, anemia, and even depressed immunity are common. These and other conditions in the post-bariatric, massive weight loss (MWL) patient create increased risks of complications, three of which will be explored in this article.
3 Complications of Body Contouring Surgery
Seromas are common in body contouring procedures and result when surgically created cavities fail to close, seal, and heal. Seromas can result from large liposuction procedures as well as procedures that remove a significant amount of tissue and require flap closure.
Seroma [se-ro´mah] can be defined as a collection of serum in the body, producing a tumor-like mass. Serum is the fluid component of blood. Seromas will also contain cells, and some blood; the color of seromas can range from straw-colored to red or rust colored.
Abdominoplasty is an excellent model to understand seroma formation and treatment. During an abdominoplasty, the skin/fat apron is elevated off of the abdominal muscle strength layer (called fascia). After the muscles are repaired, the redundant skin/fat apron is removed, and the flap is closed.
Surgical dissection in a tummy tuck creates a large surface area of raw tissue comprised of the undersurface of the skin/fat apron, and the superficial surface of the fascia that is hermetically sealed at the suture line. The raw surface area is much like a skinned knee that we all experienced as children. The raw surface oozes blood for some days before clotting.
The tissue surface also leaks lymph and tissue fluid, but unlike blood, these components have no clotting factors and may continue to leak for quite some time.
A seroma will form if the leaking fluid accumulates between the flap and the fascia. As more fluid accumulates, the fluid chamber enlarges and prevents the flap and abdominal fascia from contracting, sticking together, sealing, and healing.
If the seroma persists for a length of time, the walls of the cavity start to change in appearance and function. Typically, the fluid-filled cavity walls take on a smooth, shiny appearance, not unlike the inside of a water balloon. This shiny wall or bursa begins to produce seroma fluid, and in many cases, will not stop.
Anything that prevents the abdominal flap from adhering to the abdominal fascia predisposes to a seroma. Excessive or exuberant movements cause shearing between the tissues and disrupt the healing/sealing. Inadequate drainage of the operative site may lead to seroma. Larger surface areas of raw tissue are more prone to seroma formation. Thicker abdominal fat pads or the higher BMIs also increase the risk of seroma. Malnutrition and metabolic disturbances are also factors in seroma formation.
Although seromas cannot always be prevented, measures can be taken to minimize risks. These measures include placing surgical drains, placing quilting sutures, applying binders, and operating on smaller patients (smaller raw surface area), with lower BMI’s. Correcting nutritional, metabolic, and other health issues are also crucial to minimize risk prior to surgery.
Successful treatment of seromas is frustrating, difficult, and time-consuming. Initial treatment usually consists of aspirating the fluid collection with a needle and syringe. Fluid aspiration is usually performed every few days until the seroma resolves. If aspiration is not successful, sclerotherapy may be performed. Sclerotherapy may also be performed concurrently with aspiration. A drain may also be reinserted.
Sclerotherapy /scle·ro·ther·a·py/ (skler?o-ther´ah-pe) simply involves an injection of a chemical irritant to produce inflammation and eventual fibrosis and obliteration of the lumen. Doxycycline and 95% ethanol (alcohol) are two sclerotherapy agents that are commonly used.
Sclerotherapy is a simple office procedure performed by inserting a small drainage tube through the skin and into the bursa. The seroma is drained and sclerosing agents are instilled (usually mixed with numbing medicine to make the procedure painless), and allowed to sit for about 40 minutes. The patient’s position is usually changed several times to encourage the solution to reach all areas of the bursa. Sclerotherapy is usually repeated about three times before surgical correction is considered.
If sclerotherapy fails, surgical correction is indicated. Surgical correction is usually performed in the operating room under general anesthesia. The original incision is usually opened and the bursa is removed from the normal healthy tissue using various surgical techniques. The wound is closed over drains. Quilting sutures may be placed, or tissue glue may be used to ensure that the seroma is successfully resolved. A compression garment is integral to treatment.
2. Tissue Loss/Necrosis
Tissue loss or necrosis usually results from the disruption of the blood supply to the tissue, however, it can result from infections, or burns such as may result from a laser, Vaser, or ultrasound procedures. The seriousness and treatment options of this complication depend on the size and location of the necrotic tissue.
The most common reason for tissue necrosis occurs with body contouring procedures that utilize flaps for wound closure. In order to create flaps (such as those created during tummy tucks), tissue must be elevated, moved, and placed under tension. Some of the blood supply to the tissue is disrupted during the surgery, compromising viability. Abdominal binders further constrict blood flow and increase the risk of tissue necrosis. All of these factors strain the ability of the tissues to remain alive.
The most common site of tissue loss is in the midline at the incision. However, necrosis may occur anywhere in the flap.
Treatment options really depend on the size of the necrotic area. If the area is small, the best option may be to treat the wounds with dressings and perhaps antibiotics (such as topical Silvadene or Bactroban, and oral/intravenous antibiotics as needed). Frequent dressing changes are safe and effective, but healing may take a long time, and dressing changes may be uncomfortable or a bit painful, especially early on.
For larger areas of tissue loss, where possible, surgical excision/removal with suture closure may be possible. This is an ideal situation because when successful, healing is usually quicker, involves no dressing changes, and is usually a quicker recovery.
For large wounds that cannot be closed after wound debridement (removal of unhealthy tissue), options usually include skin grafting or VAC therapy.
Skin grafting is a mainstay of managing large wounds. Grafting is performed by removing skin from a donor area where the skin is plentiful. Usually, only the top layers are removed so that the donor site can regenerate the skin.
Skin grafting is a suboptimal solution at best. Cosmetically, skin grafts are inferior, and mechanically, they are not as durable as natural skin. Additionally, the donor site will form a scar and can be quite painful during the recovery period.
3. Bleeding and Blood Loss Complications
Some degree of blood loss will occur with any cut or operation and is to be expected. For the sake of this discussion, bleeding, and blood loss will only be considered a complication if an unplanned transfusion is required.
MWL patients are at particular risk for bleeding complications for a number of reasons unique to the weight loss journey and the nature of the specific contouring operations. As people gain weight, fat is added to the frame. Fat is a living tissue that requires increasing blood supply as its mass increases. The body responds by growing new blood vessels and increasing the diameter of existing ones. After weight loss, the number and size of the vessels do not decrease. These enlarged vessels predispose MWL patients to significant blood loss during surgery.
Contouring procedures in MWL patients were originally developed for non-obese patients to improve cosmetic appearance. Overall, the anatomy of MWL patients is the same as non-MWL patients with the exception that the amount of tissue to be removed in MWL patients is generally much greater.
The tissue that is removed contains blood, and the larger the amount of tissue that is removed, the greater the blood loss. The blood loss is increased significantly when multiple body areas are contoured concurrently. Liposuction is frequently performed as an adjunct or additional procedure, and blood is always removed along with fat, thereby adding to blood loss.
In my professional experience, I have found that post-bariatric patients are almost always dehydrated and usually malnourished to some extent. Some bariatric procedures (e.g., R-N-Y Gastric Bypass) will predispose patients to metabolic disturbances that may compromise the ability to clot.
Additionally, chronic anemia (low blood count) is common. Many patients are on medications that may inhibit the clotting mechanisms (e.g., NSAIDSs), anticoagulants, over the counter supplements and natural remedies such as St. John’s Wort, garlic, etc.). Any one of these factors could lead to increase bleeding risk and/or the need for an unanticipated transfusion.
Knowledge is Power!
In order to minimize your risks from cosmetic surgery procedures after MWL, it is imperative to undergo a thorough health evaluation before surgery and optimize your health. The things that are under your control include smoking (stop), diabetes/sugar control, blood pressure control, anemia, nutrition, metabolic disturbances, hormonal abnormalities, physical fitness, blood thinners, and the choice to do less surgery at a time. Optimize all health issues before surgery to improve your chances of having a safe surgical experience.
Always remember, cosmetic rehabilitation after MWL is a want, not a need so safety must always be the first concern!